Norwalk Community College 188 Richards Avenue Norwalk, CT HEALTH ASSESSMENT FORM for Students participating in Clinical Activities

CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM Capital Community College, Gateway Community College, Naugatuck Valley Community College, Northwestern Connecticut Community College, Norwalk Community College, Three Rivers Community College www.ct.edu/nursing Follow these guidelines to complete your Castle Branch, Inc. submission in accordance with the STUDENT INSTRUCTIONS F NWALK COMMUNITY COLLEGE NURSING (next page) All documents are submitted either by uploading the file or sending by fax. If sending documents by fax use the cover sheet provided by Castle Branch or your document will not load correctly. The Health form that is completed by your healthcare provider needs to be submitted several times for multiple requirements. For instance, you will submit it for each of the following: the physical exam requirement, the Tetanus booster requirement, the Hepatitis B immunization series requirement and TST (Tuberculosis Skin Test) or any additional documentation. Castle Branch cannot move your form from one requirement to another. The flu immunization requirement is not due until the end of October; it must be the new serum for the coming fall. If you submit one from the prior flu season, it will be rejected. If you continue to see, Incomplete or Rejected next to a requirement when you check your status something needs your attention. If you think, you have already submitted a document but it does not clear within a week, contact customer service at Castle Branch for follow up. Their number is on the bottom of their instruction sheet (next page) and on the website. It is your responsibility to submit all documents prior to the deadline and to follow up on any renewal notices sent to you by Castle Branch. Be sure you give them a valid email address that you check regularly. If you ignore their messages and requirements and you are not updated, you risk your status in the program. You cannot attend clinical unless you have met all requirements AND Castle Branch has cleared you on all requirements. You only need to purchase the Medical Document Manager Package at this time. Drug screen and background check are done in second year.

How to Place Order Welcome to To place your order go to: Package Name (if applicable): Place Order Select Program Select package To place your initial order, you will be prompted to create your secure mycb account. From within mycb, you will be able to: View order results Upload documents Manage requirements Place additional orders Complete tasks Please have ready personal identifying information needed for security purposes. The email address you provide will become your username. Contact Us: 888.914.7279 or servicedesk.cu@castlebranch.com

Norwalk Community College / Division of Nursing & Allied Health, Student Name: Date of Birth: / / Date of Physical Exam: Banner ID@ Phone: 1) 2) Emergency Contact Name Phone: 1) 2) TO THE EXAMINING PHYSICIAN / HEALTH CARE PROVIDER (HCP): Based on my health assessment and physical exam: Student DENIES Latex Allergy Student CONFIRMS Latex Allergy Student is clear to participate in clinical courses with no restrictions^. yes no* *If no, please explain the nature of the restrictions/limitations related to the delivery of patient care: ^See Technical Standards, a sample of abilities & characteristics needed to complete program requirements, attached. IMMUNIZATION RECD Refer to the CDC Healthcare Personnel Vaccination Recommendations at http://www.immunize.org/catg.d/p2017.pdf REQUIRED TITERS MUST BE POSITIVE PER LABATY STANDARD and MUST ACCOMPANY THIS FM If not immune, immunization series may need to be administered and a second titer may be required. 1. MMR: MEASLES (RUBEOLA), MUMPS & RUBELLA (GERMAN MEASLES), see https://www.cdc.gov/mmwr/pdf/rr/rr6204.pdf Evidence of vaccination per the schedule below on or after first birthday: Dose 1: / / Dose 2: / / (4 weeks after Dose 1) Titer results (attached): POSITIVE NEGATIVE (Qualitative or Quantitative titer, laboratory report attached) 2. VARICELLA (CHICKEN POX) History of Disease, Date: / / Note: documentation must be provided by a healthcare provider Titer results (attached): POSITIVE NEGATIVE (Qualitative or Quantitative titer, laboratory report must be attached) Dose 1: / / Dose 2: / / (at least 28 days apart) Booster: / / (if needed) For HCP born before 1957 see http://www.immunize.org/catg.d/p2017.pdf 3. TETANUS/DIPHTHERIA/PERTUSSIS (Tdap) see https://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html Tdap Dose: / / (within last 10 years) Td (Tdap) Booster: / / (if Tdap was > 10 years ago) 4. HEPATITIS B: Quantitative titer is required following vaccination series: Titer results (attached): POSITIVE (anti-hbs >_ 10 miu/ml) NEGATIVE (at least 2 months after final dose) vaccination with a 2-dose series of Heplisav-B a 3-dose series of Engerix-B or Recombivax HB, followed by a titer Dose 1: / / Dose 2: / / (~1 month later) Dose 3: / / (~ 5 months later) for Engerix-B or Recombivax HB only For Hep B Non-responders see http://www.immunize.org/catg.d/p2017.pdf ANNUAL IMMUNIZATION REQUIREMENTS: 1. Tuberculosis Testing is required every year, options as below: TB Skin Test (TST): INITIAL TST MUST be a two-step test #1 Date Given: Date Read: Result negative positive #2 Date Given: Date Read: Result negative positive TB Blood Test (IGRA, i.e. Quantiferon) Date of Blood Draw: Results (attached): If either test is positive a chest x-ray required Date of X-Ray: Result: normal abnormal 2. Influenza (Flu) Vaccination is required each year, contact your college for the due date Healthcare Provider Print Name Healthcare Provider Signature DEA Number DATE Address: Telephone ( )

CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Naugatuck Valley Community College, Northwestern Connecticut Community College, Norwalk Community College, Three Rivers Community College Technical Standards The CT-CCNP Technical Standards reflect a sample of performance abilities and characteristics necessary to successfully complete the requirements of the nursing program; these standards are not admission requirements. The student is responsible for notifying the nursing director and the Disability Services Coordinator of conditions that may impact the student s ability to meet the Technical Standards. Requirements Standards Examples Acquiring fundamental knowledge Developing communication skills 1. Ability to learn in classroom and educational settings 2. Ability to find sources of knowledge and acquire the knowledge 3. Ability to be a life-long learner 4. Novel and adaptive thinking 1. Communication abilities for sensitive and effective interactions with patients (persons, families and/or communities) 2. Communication abilities for effective interaction with the health care team (patients, their supports, other professional and nonprofessional team members 3. Sense-making of information gathered from communication 4. Social intelligence Acquire, conceptualize and use evidence-based information from demonstrations and experiences in the basic and applied sciences, including but not limited to information conveyed through online coursework, lecture, group seminar, small group activities and physical demonstrations Develop health care solutions and responses beyond that which is rote or rule-based Accurately elicit or interpret information: medical history and other info to adequately and effectively evaluate a client or patient s condition Accurately convey information and interpretation of information using one or more means of communication (verbal, written, assisted (such as TTY) and/or electronic) to patients and the health care team Effectively communicate in teams Determine a deeper meaning or significance in what is being expressed Connect with others to sense and stimulate reactions and desired interactions

CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Naugatuck Valley Community College, Northwestern Connecticut Community College, Norwalk Community College, Three Rivers Community College Requirements Standards Examples Interpreting data 1. Ability to observe Obtain and interpret information from patient conditions and assessment maneuvers such as responses to health and assessing respiratory and cardiac illness function, blood pressure, blood sugar, 2. Ability to assess and neurological status, etc. monitor health needs Obtain and interpret information from 3. Computational thinking diagnostic representations of 4. Cognitive load physiologic phenomena during a management comprehensive assessment of patients Obtain and interpret information from assessment of patient s environment and responses to health across the continuum Obtain and interpret for evaluation information about responses to nursing action Translate data into abstract concepts and to understand data-based Integrating knowledge to establish clinical judgment 1. Critical thinking, problem-solving and decision making ability needed to care for persons, families and/or communities across the health continuum and within (or managing or improving) their environments in one or more environments of care 2. Intellectual and conceptual abilities to accomplish the essential of the nursing program (i.e. CT- CCNP Student Learning Outcomes & Competencies) 3. New-media literacy 4. Transdisciplinarity 5. Design mindset reasoning Accomplish, direct or interpret assessment of persons, families and/or communities and develop, implement and evaluate of plans of care or direct the development, implementation and evaluation of care Critically assess and develop content that uses new media forms, and to leverage these media for persuasive communication Literacy in and ability to understand concepts across disciplines Represent and develop tasks and work processes for desired outcomes

CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Naugatuck Valley Community College, Northwestern Connecticut Community College, Norwalk Community College, Three Rivers Community College Requirements Standards Examples Incorporating appropriate professional attitudes and behaviors into nursing practice 1. Concern for others, integrity, ethical conduct, accountability, interest and motivation 2. Acquire Interpersonal skills for professional interactions with a diverse population of individuals, families and communities 3. Acquire Interpersonal skills for professional interactions with members of the health care team including patients, their supports, other health care professionals and team members 4. Acquire the skills necessary for promoting change for necessary quality health care 5. Cross-cultural competency 6. Virtual collaboration Maintain effective, mature, and sensitive relationships with clients/patients, students, faculty, staff and other professionals under all circumstances Make proper judgments regarding safe and quality care Function effectively under stress and adapt to changing environments inherent in clinical practice Demonstrate professional role in interactions with patients, intra and inter professional teams Operate in different cultural settings (including disability culture) Work productively, drive engagement, and demonstrate presence as a member of a virtual team The CT-CCNP Technical Standards have been adapted from Marks, B., & Ailey, S. A. (2014) White Paper on Inclusion of Students with Disabilities in Nursing Educational Programs. Sacramento, CA: California Committee on Employment of People with Disabilities (CCEPD).